Provider Demographics
NPI:1013172600
Name:CRISCO, JAMES JEFFREY (PHD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:JEFFREY
Last Name:CRISCO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3636 N 124TH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-2125
Mailing Address - Country:US
Mailing Address - Phone:414-476-9755
Mailing Address - Fax:414-476-3413
Practice Address - Street 1:3636 N 124TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-2125
Practice Address - Country:US
Practice Address - Phone:414-476-9755
Practice Address - Fax:414-476-3413
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI613-057103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39010900Medicaid